Every finding on record at Fernhill Rehabilitation and Care

Based on observation, interview and record review it was determined the facility failed to ensure kitchen food preparation areas were maintained in a clean and sanitary manner for 1 of 1 kitchen reviewed for sanitary kitchen practices. This placed residents at risk of illness and contaminated food. Finding include: Review of the US Food and Drug Administration 2022 Food Code indicated:The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence.The initial kitchen tour on 8/4/25 at 9:15 AM and follow-up kitchen visits on 8/6/25 at 9:02 AM and 8/7/25 at 10:01 AM revealed the following: -hundreds of small bugs with wings were observed on the windowsill above the food prep sink, in the food prep sink and on the steel counter where food was prepared. In addition, there were hundreds of small bugs caught in a bug trap sitting on the right side of the windowsill. Bugs were observed flying in the kitchen area near the clean food prep area and in the sanitary cleaning bucket used to wipe down food prep areas. -caulking along the windowsill above the food prep sink was missing and uncleanable. -there was a rancid odor emanating from under the food prep sink. On 8/4/25 at 9:23 AM and 8/7/25 at 10:01 AM, Staff 12 (Dietary Manager) stated they had been having trouble with small bugs with wings for a while. She confirmed there were hundreds of bugs on the windowsill above the food prep sink. Staff 12 stated in the afternoons, the bugs started swarming the window and windowsill which resulted in the window and windowsill being covered with bugs. Staff 12 stated the small bugs started migrating from the windowsill to the food prep sink and counters, so the kitchen staff had to move equipment and limit areas where they prepared food. Staff 12 stated the bugs flew around the kitchen and bit kitchen staff. Staff 12 stated the rancid smell under the food prep sink had been there for a while, the facility tried different things to identify and treat the smell, but the rancid odor persisted. Staff 12 stated the smell was worse on some days compared to others and smelled liked a dead animal.

Based on interview and record review it was determined the facility failed to provide a written grievance resolution or communicate with a resident or resident's representative regarding the resolution of a resident grievance for 1 of 3 (#36) sampled residents reviewed for personal property. This placed residents at risk for unaddressed concerns and grievances. Findings include:The facility's 6/1/25 Resident Grievance & Investigation Policy & Procedure directed residents and staff to complete a grievance form with concerns. Grievances were to be conducted and documented on the Resident Grievance Investigation Form with in five working days. Grievances would be documented on a grievance form and kept in a binder to track and trend concerns Resident 36 was admitted to the facility in 2024 and had diagnoses including depression and anxiety. A 5/9/25 Annual MDS indicated Resident 36 had a BIMS score of 14 which indicated she/he was cognitively intact. On 8/4/25 at 3:17 PM Resident 36 stated she/he had multiple items that were missing and no one did anything about it. The resident stated staff were very aware she/he had concerns of the missing items. The resident expressed no knowledge if these items were being investigated or any resolutions. On 8/5/25 at 4:07 PM the Grievance binder was reviewed for Resident 36's possible grievances. The binder was reviewed from 1/2025 through 8/2025 and revealed four grievances by Resident 36. The Resident Grievance Forms failed to provide resolutions to the concerns, no signatures and no evidence the resident was notified of the investigation. On 8/7/25 at 3:16 PM Staff 10 (Social Services Director) acknowledged she was responsible for following up on the resident grievances. Staff 10 stated the grievances were a work in process and confirmed Resident 36's grievance forms were incomplete and she was not able to provide evidence the resident was notified of the results of any the grievances. On 8/7/25 at 3:25 PM Staff 1 (Administrator) stated he expected all resident grievances to receive a response within five days and the forms should be completed thoroughly to allow for effective trend tracking. He acknowledged the facility had not followed the resident grievance process to investigate concerns and provide residents with documented outcomes.

Based on interview and record review it was determined the facility failed to provide resident council members with responses to concerns identified in resident council for 2 of 4 meetings reviewed for resident council. This placed residents at risk for delays in addressing care related concerns and diminished quality of life. Findings include:A 2/2021 Resident Council facility policy states, A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern.Resident Council meeting records from 2/25/25 included concerns discussed in the following areas:- residents not receiving toe nail care,- laziness of staff, - cleanliness of the facility on weekends,- care conferences not being provided, - snacks not being assessable at night,- challenges with being able to go outside,- food being cold, and- wanting more fresh fruit.Resident Council meeting records from 7/28/25 included concerns discussed the following areas:- doing community outings,- clothing being lost in laundry,- call lights not being answered, and- not responding to or belittling resident concerns. Review of Resident Council meeting records dated 2/25/25 and 7/28/25 revealed the facility did not address and of the concerns reported during those meetings. No verbal or written responses to the identified concerns were provided to Resident Council members.On 8/7/25 at 10:27 AM Staff 6 (Activities Director) stated she assisted with recording concerns from Resident Council meetings and provided the information to the appropriate department. Staff 6 stated she did not receive any response from staff. On 8/7/25 at 11:32 AM during a Resident Council interview with Resident 2, Resident 24 and Resident 41, the residents stated they identified areas of concern and provided information in writing regarding those concerns to Staff 6 but had not received any response regarding the identified concerns. On 8/7/25 at 12:26 PM Staff 2 (DNS) stated she had not received any information regarding concerns communicated by Resident Council on 7/28/25. On 8/7/25 at 1:05 PM Staff 12 (Dietary Manager) stated she responded verbally with regards to snacks but was not instructed to provide a written response to Resident Council's concerns. On 8/7/25 at 12:54 PM Staff 20 (Housekeeping Manager) stated she had never received any information from the Resident Council regarding laundry concerns.On 8/7/25 at 2:01 PM Staff 1 (Administrator) stated concerns raised during Resident Council meetings were discussed verbally among staff. Staff 1 confirmed no direct communication was provided to the Resident Council regarding the 2/25/25 and 7/28/25 meetings.

Based on observations, interviews and record review it was determined the facility failed to implement a comprehensive person-centered care plan for 1 of 2 sampled residents (#3) reviewed for accidents. This placed residents at risk for injury related to falls. Findings include:Resident 3 was admitted to the facility in 5/2025 with diagnoses including chronic kidney disease and dementia.A 7/9/25 Significant Change MDS and associated CAA's revealed Resident 3 had experienced falls since admission and her/his functional and cognitive decline placed them at increased risk for injury related to falls.The 7/23/25 Care Plan identified the intervention to have Resident 3's call light within reach and encourage her/him to use it for assistance.On the following occasions Resident 3's call light was observed to be out of reach: -8/5/25 at 8:38 AM-8/5/25 at 3:12 PM-8/6/25 at 8:48 AM-8/6/25 at 10:14 [NAME] 8/5/25 at 8:07 PM Staff 7 (CNA) stated Resident 3 experienced recent falls and knew how to use the call light appropriately.On 8/6/25 at 10:15 AM Staff 8 (CNA) stated Resident 3 experienced more falls recently and that he rounded on the resident hourly. Staff 8 stated he ensured Resident 3's call light was within reach and reminded her/him to use it for help. When Staff 8 entered Resident 3's room while the resident was in bed, they acknowledged the call light was on the floor.On 8/6/25 at 11:25 AM Staff 4 (LPN RCM) stated staff was expected to check for location of call lights every time they were in a resident's room. Staff 4 acknowledged call lights should always be within residents' reach.

Based on observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interest and preferences for 1 of 1 sampled resident (#36) reviewed for activities. The failure to provide meaningful and preferred activities placed residents at risk for unmet psychosocial needs. Findings include:Resident 36 admitted to the facility in 2024 with a diagnoses including anxiety and major depression.Resident 36's 5/9/25 Annual MDS assessed her/him as cognitively intact. Resident 36 was assessed with leisure interest of the following importance to her/him: Very important: outside to fresh air; to do your favorite activities. Somewhat important: do things with groups of people; pets; listen to music. Not very important: Religious; news; books/reading materials.Resident 36's 3/26/25 Activity admission Assessment (readmission) assessed her/him as completely independent in her/his leisure pursuits, and enjoyed music, walking/wheeling outdoors, watching television, talking, helping others, and to vote.On 8/4/25 at 3:21 PM Resident 36 stated she/he was often bored and nothing on the group calendar interested her/him except Bingo. Resident 36 stated she/he did not have any music to listen to in the room but could watch television. The 8/6/25 care plan for Resident 36 directed staff to assist with one-on-one Chaplin visits, she/he was a Christian, liked to watch television, hunting and fishing interests, socializes with others and to invite to Bingo group. Multiple observations were made between 8/5/25 at 1:37 PM to 8/7/25 at 2:00 PM of Resident 36 not involved in leisure activities or a Bingo group.Review of Resident 36's activity participation from 7/5/25 to 8/6/25 revealed she/he had attended one Bingo group, attended an unidentified group, went outside two times, participated in individual activities on two occasions.On 8/7/25 at 3:54 PM Staff 6 (Activity Director) confirmed Resident 36 was identified as religion not being important to her/him and was care planned for religious activities. Staff 6 acknowledged the lack of documentation for Resident 36 for activity participation. Staff 6 stated it was difficult to plan activities to keep the interests of all residents.On 8/7/25 at 4:24 PM Staff 1 (Administrator) stated he expected personalized activities to be provided for each resident and acknowledged the need for improvement in this area to increase resident engagement. Staff 1 stated he expected resident participation in activities to be documented.

Based on observation and interview it was determined the facility failed to provide a homelike environment for 2 of 3 hallways reviewed for environment. This placed residents at risk for a lack of homelike environment. Findings include:1. Resident 36 admitted to the facility in 2024 with a diagnosis including congestive heart failure. A 5/9/25 Annual MDS assessed Resident 36 with a BIMS score of 14 which indicated she/he was cognitively intact. During an observation on 8/4/25 at 3:22 PM a personal fan located on the bedside table of Resident 36 and was noted to have a thick, visible accumulation of dust, lint, and grime coating the fan blades. and protective grill. The buildup appeared grey in color, layered, and had visibly adhered to the surfaces. On 8/5/25 at 10:58 AM Resident 36 stated she/he wanted her/his fan cleaned and had been waiting for staff to clean it. On 8/5/25 at 11:23 AM Staff 20 (Housekeeping Supervisor) stated housekeepers were responsible to clean resident’s personal fans. On 8/5/25 at 11:27 AM Staff 1 (Administrator) observed Resident 36’s personal fan, confirmed it needed to be cleaned and stated he expected all personal fans to be clean. 2. Observations on 8/4/25 through 8//7/25 between the hours of 9:00 AM and 4:00 PM revealed the following: -room [ROOM NUMBER]: The walls to the left and across from bed D had numerous scrapes and areas that required painting, the closet was scraped and had residual masking tape on the door and there were missing pieces of wood on the left portion of the bottom closet drawer which were uncleanable. There were multiple holes in the wall to the right of the hand sanitizer dispenser. The center bed area had a large, patched area near the electric outlet that required painting. The wall at the head of bed W had deep scrapes needing repair. -room [ROOM NUMBER]: The walls behind and to the right of the head of bed were scraped, the wall under the window had multiple vertical scrapes and there were multiple screws in the wall across from the bed. -room [ROOM NUMBER]: There were multiple scrapes on the heater, nails and screws in the walls to the left of the bed, and splashes and streaks of an unknown substance at the head of and beside the bed. The vent in the ceiling above the resident was covered in dust build-up, the resident's bedside table was sticky, and the wheels stuck when attempting to move the table. On 8/4/25 at 9:52 AM and 11:31 AM, Resident 17 (room [ROOM NUMBER]) stated they don't clean anything for me. Resident 17 and Resident 52 (room [ROOM NUMBER]) both stated their rooms required cleaning and repairs and the rooms were not homelike. On 8/7/25 at 9:32 AM, Staff 11 (Maintenance Director) stated each resident room needed repairs, painting and updating and confirmed the resident rooms identified were not homelike. On 8/7/25 at 12:30 PM, Staff 1 (Administrator) stated he expected resident rooms to be homelike and confirmed the identified resident rooms required attention.

Based on observation, interview and record review it was determined the facility failed to ensure accurate MDS assessments were completed for 1 of 1 sampled resident (# 41) reviewed for dental. This placed residents at risk for an inaccurate picture of the resident's status. Findings include:Resident 41 was admitted to the facility in 4/2020 with diagnoses including a stroke. On 8/4/25 at 10:28 AM and 8/6/25 at 1:46 PM, Resident 41 was observed to have no upper teeth and missing molars on both sides of the lower jaw with observed difficulty chewing some food textures including cucumbers and large pieces of lettuce. Resident 41 reported she/he had missing upper teeth with three broken tooth fragments and missing teeth on both sides of her lower mouth. Resident 41 stated she had difficulty chewing hard food items. Resident 41's 7/14/25 Quarterly MDS indicated Resident 41 had no cognitive impairment and no difficulty chewing food. Resident 41's 4/13/25 Annual MDS indicated Resident 41 had no cognitive impairment and Resident 41 had no natural teeth or tooth fragments, no obvious or likely broken natural teeth and no difficulty chewing. On 8/7/25 at 10:38 AM, Staff 2 (DNS) verified Resident 41's MDS' were inaccurate and stated her expectation was Resident 41's MDS assessments were correct and accurately reflected the resident's dental status.

Based on interview and record review it was determined the facility failed to return a power wheelchair to 1 of 3 resident (#51) reviewed for personal property. This placed residents at risk for decrease independence with mobility. Findings include:Resident 51 was admitted to the facility in 3/2024 with diagnoses including congestive heart failure. A 3/18/24 admission MDS revealed Resident 51's had a BIMS score of 15, which indicated the resident was cognitively intact. On 5/16/24 Resident 51 was transferred to the hospital due to a change in condition and did not return to the facility. Review of the resident's medical records revealed no attempt was made to return Resident 51's power wheelchair to Resident 51 after her/his discharge.On 8/5/25 at 12:57 PM and on 8/6/25 at 9:46 AM Staff 10 (Social Service Director) stated Resident 51 was admitted to the facility and utilized her/his power wheelchair. Staff 10 stated Resident 51 was discharged and transferred to another nearby facility, and the resident's power wheelchair was never delivered to her/him.On 8/6/25 at 10:01 AM Staff 11 (Maintenance Director) stated Resident 51's power wheelchair was kept in a storage shed for six months after the resident discharged . Staff 11 stated he was instructed and disposed of Resident 51's power wheelchair during 10/2024. On 8/6/25 at 12:26 PM Staff 1 (Administrator) stated Resident 51's power wheelchair was found to be non-operational during a large cleanup of the storage area in 10/2024. Staff 1 confirmed Resident 51's power wheelchair was disposed of and not returned to Resident 51.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by Resident 27 for 1 of 4 sampled resident (#24), reviewed for abuse. This placed residents at risk for additional physical abuse. Findings include:Resident 27 admitted to the facility in 2018 with a diagnosis including a stroke.Resident 24 admitted to the facility in 2024 with diagnoses including depression, scoliosis (abnormal spine).The facility's 1/3/25 Investigation summary concluded from Resident 24's statement she/he woke around 4:00 AM on 12/31/24 and saw Resident 27 in her/his room. When Resident 24 tried to stand up, Resident 27 pushed her/him down onto the bed and proceeded to hold the door shut from the outside. Resident 24 called the police and told staff what had happened.On 8/7/25 at 1:48 PM Staff 1 (Administrator) confirmed physical abuse occurred when Resident 27 pushed Resident 24 onto the bed on 12/31/24. Staff 1 stated all residents were to be free from any type of abuse.

Based on interviews and record review it was determined the facility failed to report allegations of physical abuse within the mandated timeframe for 1 of 4 sampled residents (#24) for 1 of 2 Facility Reported Incident (FRI) reports reviewed for abuse. This placed residents at risk for further abuse. Findings include:The facility's revised 4/2021 Abuse, Neglect, Exploitation or Misappropriation Prevention Program policy and procedure directed staff to report allegations of abuse within the required timeframes.On 12/31/24 at 11:11 AM, the state agency (SA) received a FRI for the 12/31/24 at 4:00 AM alleged abuse of Resident 24 by Resident 27. The FRI revealed Resident 27 entered Resident 24's room and pushed her/him onto her/his bed, then left and held the door shut from the outside so Resident 24 could not leave the room.On 8/7/25 at 1:48 PM Staff 1 (Administrator) stated he was not informed of the incident until his morning meeting approximately 9:30 AM. He confirmed the incident occurred and staff were aware of the incident at 4:00 AM on 12/31/25. Staff 1 acknowledged the FRI was submitted late to the State Agency (SA).

Based on observation, interview and record review it was determined the facility failed to obtain dental services for 1 of 1 sampled resident (#41) reviewed for dental services. This placed residents at risk for unaddressed dental care needs. Findings include:The facility's Dental Services policy, dated 3/2021, indicated the following: -The social services representative would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. -All dental services provided were recorded in the resident's medical record. Resident 41 was admitted to the facility in 4/2020 with diagnoses including a stroke and diabetes. Resident 41's 4/13/25 Annual MDS indicated the resident had no cognitive impairments. Resident 41's 5/19/25 oral/dental health care plan indicated the resident was missing her/his top teeth and the majority of her/his lower teeth. Interventions included coordinating arrangements for dental care and transportation as needed/ordered. A review of Resident 41's electronic record revealed no evidence the resident was seen by a dentist. On 8/4/25 at 10:28 AM and 8/7/25 at 8:17 AM Resident 41 was observed with no upper teeth and only a few lower front teeth which appeared chipped and worn. Resident 41 stated, for the past four months, she/he had been asking Staff 10 (Social Service Director) to schedule an appointment with an outside dental provider because she/he needed three tooth fragments removed from her/his upper gums and the lower teeth pulled so she/he could be fitted for dentures. On 8/5/25 at 2:05 PM, Staff 10 stated she was aware Resident 41 requested to see an outside dental provider and confirmed no appointment was scheduled. On 8/7/25 at 8:26 AM, Staff 4 (LPN-Care Manager) stated she was aware Resident 41 wanted to see an outside dental provider for at least the past few months. Staff 4 stated she was unaware if an appointment was scheduled. On 8/7/25 at 12:40 PM, Staff 2 (DNS) stated Resident 41's outside dental appointment was not yet scheduled and her expectation was the resident's dental appointment should have been scheduled in a more timely manner.

Based on observation, interview and record review it was determined the facility failed to obtain vision services for 1 of 1 sampled resident (#41) reviewed for vision. This placed residents at risk for not adequately addressing vision related needs. Findings include:The facility's Care of the Visually Impaired Resident policy, dated 3/2021, indicated it was the facility's responsibility to assist the resident and representatives in locating available resources, scheduling appointments and arranging transportation to obtain needed services. Resident 41 was admitted to the facility in 4/2020 with diagnoses including a stroke and diabetes. A 3/4/25 Ocular (related to the eyes) Progress Note completed by the facility optometrist (an eye care specialist) indicated Resident 41 was referred to a retina specialist (a medical doctor specializing in the diagnoses and treatment of eye diseases and conditions) on 2/1/24 but the resident was not seen by a specialist. Recommendations instructed the facility to follow-up regarding Resident 41's 2/1/24 referral because the resident reported a continual decline in her/his vision. Resident 41's 4/13/25 Annual MDS indicated the resident had no cognitive impairment and Resident 41 wore corrective lenses and was able to see in adequate light with glasses or visual appliances. Resident 41's 5/19/25 impaired visual function care plan indicated staff would arrange a consultation with an eye care practitioner as required. A review of Resident 41's electronic health record revealed no evidence Resident 41 was scheduled with or seen by a retina specialist. On 8/4/25 at 10:28 AM and 8/7/25 at 8:17 AM Resident 41 stated, for the past four months, she/he had been asking Staff 10 (Social Service Director) to schedule an appointment with an eye doctor because she/he had diabetes and, my eyes are getting really bad. Resident 41 was observed wearing glasses and stated she/he bought several pairs of reading glasses but had no prescription glasses. On 8/5/25 at 2:05 PM, Staff 10 stated she was aware Resident 41 wanted to see an eye doctor because the resident's vision was not great. Staff 10 confirmed no appointment with an eye doctor was scheduled for Resident 41. On 8/7/25 at 10:30 AM, Staff 2 (DNS) confirmed Resident 41 was not scheduled for an appointment with an eye doctor.

Based on interview and record review it was determined the facility failed to the ensure the DCSDR (Direct Care Staff Daily Report) postings were accurate for 15 of 45 days reviewed for staffing. This placed residents and visitors at risk for inaccurate staffing information. Findings include:Review of the facility's DCSDRs from 6/30/25 through 8/4/25 revealed 15 of 45 days reviewed were inaccurate or incomplete. Issues included, missing or incomplete licensed nurse staff hours, no CNA hours listed, missing census data, incorrect dates, and missing signatures. These deficiencies were noted on the following dates: 6/30/25, 7/2/25, 7/3/25, 7/9/25, 7/11/25, 7/15/25, 7/25/25, 7/26/25, 7/29/25, 7/30/25, 7/31/25, 8/1/25, 8/2/25, 8/3/25 and 8/4/25.On 8/7/25 at 3:55 PM, Staff 15 (Human Resources/Staffing Coordinator) reviewed the 6/30/25 through 8/4/25 DCSDRs and verified the reports were inaccurate or incomplete on the days identified.

Based on interview and record review it was determined the facility failed to ensure a resident did not elope for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for injury. Findings include: Resident 1 admitted to the facility in 5/2024 with a mental health diagnosis. A 5/13/24 hospital Discharge Summary revealed Resident 1 experienced houselessness for more than 40 years and was diagnosed with a mental health condition several decades earlier. Resident 1's mental health was stable until she/he refused to take all medications. Resident 1's cognition was not able to be assessed due to her/his polite refusal to answer most questions. Resident 1's Care Plan revised on 4/23/25 revealed she/he was at risk for elopement. Interventions included staff were to monitor the resident regularly, staff were to redirect, offer foods and fluids, and provide activities during Resident 1's episodes of wandering or exit seeking. Staff were also to provide 1:1 supervision until the exiting behavior resolved. Resident 1's 5/20/25 Elopement Risk Evaluation revealed she/he was cognitively impaired with poor decision-making skills, was able to walk independently without an assistive device, and her/his wandering placed her/him at risk of being in an unsafe location. The assessment indicated Resident 1's former lifestyle affected her/his current behavior and placed the resident at risk for elopement. Resident 1's 5/24/25 Annual MDS revealed she/he was independent with all ADLs, had a mental health diagnosis, refused to take medication, resulting in visual and auditory hallucinations, and the inability to ask for assistance. Resident 1's 6/9/25 Progress Notes revealed the following: - At approximately 4:20 AM a CNA called out to Staff 5 (RN) and reported Resident 1 left the facility. Staff looked for Resident 1 in the facility neighborhood, did not locate the resident, and police were notified. -At 10:45 PM police located Resident 1 seven blocks from the facility on a private residence's porch. Staff 2 (DNS) went to Resident 1's location and as soon as Resident 1 saw Staff 2, she/he stated go away, and when Staff 2 tried to encourage her/him to return to the facility, she/he stated no, I don't want to go back. Staff 2 requested Staff 3 (RNCM) to assist with the situation. -At 11:30 PM Staff 3 arrived at Resident 1's location and provided food and fluids. Resident 1 accepted the food but was resistive to any conversation related to returning to the facility. Staff 3 explained to Resident 1, if she/he did not return to the facility, she/he would be leaving against medical advice. Resident 1 voiced understanding and continued to state she/he did not want to return to the facility. On 6/11/25 at 1:41 PM Staff 7 (CNA) stated on the night shift Resident 1 usually stayed in her/his room but at times would come out for food or to use the bathroom, and did not usually go to the front door. Staff 7 stated on 6/9/25 at approximately 4:11 AM she saw Resident 1 by the front door and her/his assigned CNA (Staff 6) was in a chair monitoring her/him. Staff 7 stated Staff 6 was not too close to Resident 1 because she/he did not like staff to be in her/his bubble. Staff 7 stated she was not sure how long Resident 1 was by the front door. Staff 7 indicated at approximately 4:20 AM she heard another resident call out and reported Resident 1 left the facility. Staff 7 stated when she/he arrived to the front door Resident 1 was no longer present. Staff 7 looked in Resident 1's bedroom, hall bathroom, and did not find Resident 1. Staff then searched the outside of the facility for Resident 1 but did not locate her/him. On 6/12/25 at 4:02 PM Staff 5 stated, on the night shift, Resident 1 usually kept her/his door shut and stayed in her/his room. On 6/9/25 Staff 5 was at the nurses station and he heard a CNA call for assistance. When he arrived at the front door he was notified Resident 1 exited the facility. Staff looked for Resident 1 inside and around the facility neighborhood, but was not able to locate her/him. Staff 5 stated he notified the police. Staff 5 stated he was told Staff 6 monitored Resident 1 while she/he was at the front door, but left for a brief moment, to inform him Resident 1 was attempting to leave the facility. Staff 5 stated Staff 6 intended to write a note to place on the front door, to alert the incoming staff who might enter the front door, because Resident 1 might attempt to leave the facility. On 6/11/25 at 11:59 AM and 6/12/25 at 4:16 PM a telephone call was placed to Staff 6. A return call was not received. On 6/17/25 at 11:07 AM Staff 3 stated Resident 1 kept to herself/himself and did not frequently engage in exit-seeking behavior from the facility. Staff 3 stated Resident 1 had a mental health diagnosis and consistently refused medications which could have been beneficial. Resident 1 did not have a medical power of attorney and family declined to assume guardianship. Staff 3 stated the facility doors were locked with a posted code. Resident 1 was assessed to be at risk for elopement and staff were instructed to offer food and fluids and redirect her/him away from the door if an exit attempt was observed. Staff were to provide 1:1 supervision if Resident 1 was trying to leave the facility. On 6/17/25 at 11:38 AM, Staff 2 acknowledged she was aware of Resident 1's elopement on 6/9/25. Staff 2 stated Resident 1 was at the front door on 6/9/25 and Staff 6 had been providing supervision, but left for a short timeframe in which Resident 1 was able to exit the facility. Staff 2 stated she expect 1:1 supervision whenever Resident 1 exhibited ex-seeking behavior. Staff 2 stated Staff 6 should not have left Resident 1 unattended by the doors without supervision. The deficient practice was identified as Past Noncompliance based on the following: On 6/9/25 the deficient practice was identified by the facility and determined there was a lack of supervision for a resident at risk for elopement. The Plan of Correction included: -All staff reviewed the Wandering and Elopement policy. -Walkies (communication devices) were to be worn at all times by nursing staff on all shifts. -When a resident exhibited exit seeking behaviors staff needed to remain with the resident at all times. -Staff were to notify the DNS and the on-call nurse manager when a resident exhibited exit seeking behaviors. -Staff were reeducated to ensure residents' Kardex were reviewed for elopement interventions. -An elopement drill was performed on 6/9/25 at 11:45 PM.

Based on interview and record review it was determined the facility failed to timely assist a resident with a transfer for 1 of 3 sampled residents (#3) reviewed for accidents. As a result, Resident 3 was hospitalized and suffered a fractured femur. Findings include: Resident 3 was admitted to the facility in 2024 with diagnoses including diabetes and end stage renal (kidney) disease. Resident 3's 4/5/25 MDS Annual Assessment revealed a BIMS score of 15, indicating no cognitive deficits. Resident 3's care plan, revised 12/2/24, revealed she/he was a fall risk based on her/his medical conditions, lack of safety awareness and poor impulse control. Interventions included to keep the call light within reach and to anticipate and meet Resident 3's needs. On 11/25/24 the facility submitted a FRI to the State Survey Agency, which indicated on 11/23/24, Resident 3 attempted to self transfer from the bedside commode to the bed, fell during the attempt and was sent to the hospital. The hospital initially had no findings but the resident continued to complain of pain the following day and was sent to the hospital a second time. Resident 3 was diagnosed with a fracture of her/his right femur (thigh bone). The FRI included a statement from Resident 3, which noted she/he had a suppository and needed to use the commode. At 8:30 PM, the resident had the room light on and used the call light. Resident 3 asked the night nurse for help but she in doing wound care. At about 8:55 PM, Resident 3 stated she/he positioned the commode in front of the transfer pole and transferred herself/himself to the commode. Resident 3 noted at 9:15 PM, no staff had come to her/his room, and she/he continued to push her/his call light. Resident 3 indicated her/his leg was cramping up, so she/he stood up to stretch it, took a step to the right, let go of the transfer pole and fell on her/his right side and hit her/his right side of the face on the bottom bar of the bedside table. On 4/25/25 at 1:50 PM, Resident 3 stated she/he recalled the incident and had fractured her/his femur due to the fall. She/he stated she/he had used the bedside commode and needed /did not respond to the call light for an hour so she/he decided to transfer herself/himself. When Resident 3 stood up, her/his leg cramped as she/he attempted to step away from the commode and she/he fell . Resident 3 stated other staff heard her/him screaming and found her/him on the floor. On 4/25/25 at 2:30 PM, Staff 14 stated he was the resident's assigned CNA on 11/23/24. He confirmed he did not respond to Resident 3's call light because another resident had eloped from the facility and he went out to find the resident. Staff 14 recalled he found the missing resident and returned to the facility about an hour after he left. He stated he was unaware Resident 3 needed assistance and had been told by Staff 12 (RN) other staff could assist any residents' needs because it was almost the end of his shift. On 4/25/25 at 2:44 PM, Staff 12 stated he was working on the other hall and was not aware of Resident 3's fall. He confirmed Staff 14 had left the facility to search for an eloped resident on the evening of 11/23/24. On 4/25/25 at 4:01 PM, Staff 8 (LPN) stated she was working on Resident 3's hall on the 11/23/24 evening shift. She recalled checking in with Resident 3, who was on her/his bedside commode but the resident stated she/he wasn't done. Staff 8 stated she completed a tube feed and was on her way to the nurse's station when she heard Resident 3 screaming. She and two CNAs found the resident on the floor and the resident was sent to the hospital. Staff 8 stated this occurred close to 10:00 PM and she did not see Resident 3's assigned CNA. On 4/28/25 at 11:00 AM, Staff 1 (Administrator) and Staff 2 (DNS) were informed of the findings of the investigation and provided no additional information.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk of adverse side effects for lack of medication administration. Findings include: Resident 2 was admitted to the facility in 2/2024, with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Resident 2's 2/14/24 Physician orders revealed the resident was to receive 5 mg of apixaban (an anticoagulant medication which thins the blood) twice a day for atrial fibrillation. On 8/29/24 the State Survey Agency received a public complaint, which alleged Resident 4 did not receive her/his medication for three days following a hospitalization and re-admission to the facility. The complainant stated the resident called her on Tuesday, 8/27/25 stating she/he had a headache and had not received her/his medication since returning from the hospital the previous weekend. Progress notes from 8/22/25 through 8/24/24 indicated Resident 2 was sent to the hospital on 8/22/24 and returned to the facility on [DATE]. She/he was diagnosed with pneumonia and an antibiotic was ordered. Hospital discharge orders dated 8/24/24 indicated the apixaban was ordered to be continued at the facility. A progress note dated 8/27/24, indicated Resident 2 complained of a headache, was concerned about having a stroke and stated she/he had been taken off her/his blood thinners. Resident 2's 8/2024 MAR revealed the apixaban was not administered on 8/23/24 through 8/27/24. The MAR was coded as hold. There were no nursing notes to indicate why the medication was on hold. Review of Resident 2's 8/24/24 Admission Form revealed Staff 15 (Former LPN) was the admitting nurse. On 4/23/25 at 12:42 PM, Witness 3 (Complainant) stated she received a phone call from Resident 2 on 8/27/25 stating she/he had not received her/his apixaban since returning from the hospital the previous Saturday. Witness 3 stated she spoke to the DNS later that day and was told Resident 2 had not received her/his apixaban because the admitting nurse did not input the orders when the resident readmitted on [DATE]. On 4/24/25 at 10:35 AM, Witness 4 (Physician) stated the apixaban was not supposed to be held when the resident returned to the facility on [DATE] and he did not order the medication to be held. On 4/24/25 at 12:03 PM, Staff 9 (LPN) confirmed she administered the apixaban to Resident 2 on 8/22/24, prior to the resident going to the hospital. She stated the medication could have been pulled from the Pixus (facility emergency medication kit) if the medication was not available when the resident returned from the hospital. Staff 15 was not interviewed due to no longer working at the facility. On 4/25/25 at 12:56 PM, Staff 3 (RCM) verified the apixaban was not administered to Resident 2 until 8/27/24 and this constituted a serious medication error.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 3 sampled residents (#6) reviewed for abuse. This placed residents at risk for abuse. Resident 7 was admitted to the facility in 5/2024, with diagnoses including acute pancreatitis (a condition that inflames the pancreas) and alcohol induced disorder (a condition that triggers mood disorders due to alcohol consumption). A Behavioral Care Plan was initiated on 6/14/24 and revised on 9/12/24, which indicated Resident 7 had a history of problematic manner which were characterized through abusive language, and threats due to a history of alcohol dependence. Staff were directed to remove other residents away from Resident 7 should she/he become aggressive or initiate verbal altercations with residents or staff. In addition, care staff were instructed to remove Resident 7 from the area and provide low stimulus activities and or to leave Resident 7 in a safe area and reapproach again later. Resident 6 was admitted to the facility in 5/2024, with diagnosis including congestive heart failure and depression. A Behavioral Care Plan was initiated on 5/4/24, which indicated Resident 6 had high anxiety due to a history of homelessness and medical conditions. Staff were directed to provide resident with resources for mental health including empathy, reassurance and comfort during moments of high anxiety. A 9/7/24 Clinical Progress Note indicated Resident 7 had been drinking most of the day and engaged in a verbal altercation with Resident 6 near the smoking area. Resident 7 was identified to have punched Resident 6 in the face with her/his right hand and fell to the floor from her/his wheelchair after attempting to hit her/him again with her/his left hand. Facility assessment noted Resident 7 and Resident 6 had no injuries from the altercation. On 4/25/25 at 12:58 PM, Resident 6 confirmed she/he was hit in the face by Resident 7 during a verbal altercation that started due to Resident 6's request for Resident 7 to pick up her/his cigarette butts. Resident 6 stated Resident 7 had been drinking most of the day and was increasingly agitated as a result. Resident 6 stated Resident 7 confronted her/him and punched her/him in the face. Resident 6 stated Resident 7 had intended to hurt her/him during the altercation as Resident 7 threatened her/him just before being punched but noted that no harm had occurred after the punch. On 4/25/25 at 1:38 PM, Staff 7 (CNA) stated Resident's 7 and 6 got into a verbal altercation which resulted in Resident 7 punching Resident 6 in the face. Staff 7 stated Resident 7 had a long history of aggressive behaviors towards residents and staff and had been drinking during the day of the incident which led to an argument between Resident 7 and Resident 6. On 4/25/25 at 2:09 PM, Staff 4 (RCM) stated Resident 7 had identified verbal behaviors days before the incident. Staff 4 stated that when Resident 7 began to engage in verbally inappropriate behavior, care staff would remove the resident and or residents in the immediate area for safety. Staff 4 indicated that on the day of the incident, Resident 7 displayed no verbal behaviors while out on the patio until she/he engaged in an argument with Resident 6. Staff 4 confirmed Resident 7 punched Resident 6 in the face before falling out of her/his wheelchair on their second attempt. Staff 4 further confirmed Resident 7 had been drinking that day. On 4/28/25 at 11:03 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged findings and confirmed Resident 7 had punched Resident 6 in the face.

Based on observation, interview, and record review it was determined the facility failed to implement the plan of care for 1 of 3 sampled residents (#1) reviewed for resident safety and elopement. This placed residents at risk of an unsafe elopement. Findings include: Resident 1 admitted to the facility in 5/2024, with diagnoses including schizophrenia and dementia. Resident 1's 8/23/24 MDS Quarterly revealed a BIMS score of 0, indicating severe cognitive impairment. An elopement risk evaluation dated 8/23/24, revealed Resident 1 was a high elopement risk and she/he frequently stood by the entrance door, stating she/he wanted to leave. Resident 1's care plan dated 10/15/24 revealed she/he was an elopement risk/wanderer with a history of attempts to leave the building unattended and she/he had impaired safety awareness. Interventions were to distract the resident by offering diversions, activities, food, conversation, television or a book. On 12/3/24 at 11:39 AM, Staff 10 (CNA) stated she was Resident 1's assigned CNA. She stated staff was aware to watch the resident from leaving and to re-direct the resident. She was not able to describe how to re-direct Resident 1 and stated she had been assigned to Resident 1 twice. On 12/3/24 at 11:43 AM, Staff 11 (CNA) stated she knew Resident 1 had a history of attempting to leave the building and staff was to re-direct the resident and encourage the resident to write in her/his notebook. On 12/3/24 at 11:57 AM, Staff 12 (CNA) stated staff was supposed to watch Resident 1 because she/he liked to escape. On 12/3/24 from 11:22 AM through 12:07 PM, Resident 1 was observed in the South Hall. The resident was seated on an inoperable heating unit which was located right by the front door. Resident 1 was observed writing in a notebook and watching staff as they came into the facility and left the facility. The door was locked and required a security code to be opened from the inside, but no code was required for visitors or staff entering the facility. During the observation period, several CNAs, a Physical Therapist and other facility staff was observed in the South Hall where Resident 1 was seated. During the observation period, no staff attempted to distract or provide a diversion to Resident 1 as care planned. At 12:07 PM, Staff 18 (Activities Director) approached Resident 1 and offered her/him a drink in the Activity Director's office which the resident accepted and left her/his position at the front door. During the survey period, Resident 1 was observed seated by the front door several times writing in a notebook but was not observed attempting to leave the building. On 12/5/24 at 3:15 PM, Staff 1 (Administrator) was informed of the findings of staff not implementing Resident 1's care plan interventions and provided no additional information.

Based on observation, interview, and record review it was determined the facility failed to provide adequate supervision and failed to thoroughly evaluate and analyze an elopement for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for an unsafe elopement. Findings include: a. Resident 1 was admitted to the facility in 5/2024, with diagnoses including schizophrenia and dementia. Resident 1's 8/23/24 Quarterly MDS revealed a BIMS score of 0, which indicated severe cognitive impairment. An elopement risk evaluation dated 8/23/24 revealed Resident 1 was a high elopement risk and she/he frequently stood by the entrance door, stating she/he wanted to leave. Resident 1's most recent care plan dated 10/15/24 revealed she/he was an elopement risk/wanderer with a history of attempts to leave the facility unattended and she/he had impaired safety awareness. Interventions were to distract the resident by offering diversions, activities, food, conversation, television or a book. On 11/25/24 the facility submitted a Facility Reported Incident (FRI) report to the State Survey Agency (SSA) which revealed Resident 1 eloped from the facility on 11/23/24 at approximately 6:50 PM. The FRI stated staff in the facility initiated a search in the neighborhood and Resident 1 was found a block away at a bus stop. The resident returned to the facility with staff at approximately 7:50 PM. On 12/3/24 at 11:39 AM, Staff 10 (CNA) stated she was Resident 1's assigned CNA. She stated staff was aware to watch the resident from leaving and to re-direct the resident. She was not able to describe how to re-direct Resident 1 and stated she had been assigned to Resident 1 twice. On 12/3/24 at 11:43 AM, Staff 11 (CNA) stated she knew Resident 1 had a history of attempting to leave the building and staff was to re-direct the resident and encourage the resident to write in her/his notebook. On 12/3/24 at 11:57 AM, Staff 12 (CNA) stated staff was supposed to watch Resident 1 because she/he liked to escape. On 12/3/24 at 3:20 PM, Staff 13 (RN) stated he worked the day shift on 11/23/24. He stated he saw Resident 1 most of the day and found out she/he eloped the next day. Staff 13 stated Resident 1's exit seeking behaviors was common and the resident walked around the facility most of the time and she/he didn't talk to anyone. On 12/5/24 at 9:33 AM, Staff 14 (CNA) stated she was Resident 1's assigned CNA for the evening shift on 11/23/24. She returned from her break at approximately 6:30 PM and went to Resident 1's room to check on her/him. Staff 14 stated she was unable to locate the resident and notified the charge nurse. Staff 14 stated she and two other CNAs searched the neighborhood for the resident and she/he was found by Staff 16 (CNA) a short time later. Staff 14 stated previous interventions for the resident was to sit down in a chair right next to the resident if she/he was seated by the front door, which resulted in the resident returning to her/his room every time. On 12/5/24 at 9:40 AM, Staff 15 (CNA) stated she was not assigned to Resident 1's hall on 11/23/24, but heard about Resident 1's elopement and decided to search for her/him, along with Staff 14 and Staff 16. Staff 15 stated she observed Resident 1 headed west on a busy street and [resident name] had walked a long way and was waiting for the bus. Staff 15 attempted to talk to Resident 1 to get into her car but Resident 1 refused. Staff 15 stated Staff 16 was on foot and walked with the resident back to the facility. On 12/5/24 at 2:15 PM, Staff 16 stated he was working on the other hall and was informed by the charge nurse Resident 1 was missing. He stated let's go look for [her/him] and immediately walked along the street. Staff 16 stated he walked into a couple of businesses and did not find the resident. He continued to walk and saw Resident 1 standing at the bus stop. He stated he ran across the street to stop her/him from boarding the bus and if it would have been two minutes later, [resident name] would have been gone. Staff 16 stated he walked with Resident 1 back to the facility and the resident had no injuries, had worn a coat and boots and was fine. Observations were made of the bus stop on 12/3/24 at 4:40 PM. The intersection where Resident 1 was located was densely populated, with several businesses, pedestrians and a large amount of motor vehicles observed on both roads. The intersection was several blocks from the facility's location and not one block away, as the facility report indicated. Resident 1 was observed at the facility from 12/3/24 through 12/5/24. She/he was observed seated by the front door several times writing in a notebook but was not observed attempting to leave the facility. Resident 1 was approached by the surveyor on 12/5/24 at 2:45 PM and refused to talk to the surveyor. On 12/5/24 at 3:15 PM, Staff 1 (Administrator) was informed of the findings related to the resident's elopement. No additional information was provided. b. The facility's undated Investigation and Conclusion Report revealed Resident 1 was noted absent from the facility on 11/23/24 at 6:30 PM. A Code Yellow elopement protocol was activated, 911 was contacted and administrative staff were notified. The report only contained a statement from an unnamed nurse regarding the investigative activities. The investigation's conclusion revealed staff began searching for the resident and she/he was found at a bus stop near the facility. The findings noted it is uncertain if [resident name] let [herself/himself] out or if a visitor let [her/him] out as [she/he] is not a reliable historian due to [her/his] diagnosis of schizophrenia. Investigation initiated and employee statements were taken. The investigation did not include who completed the investigation, when the investigation was initiated and completed, and if the Administrator or DNS reviewed the investigation. The Root Cause Analysis did not address the facility's security failure which resulted in the resident eloping or how the resident left the building undetected. No CNA staff who searched for and found Resident 1, nor any CNA staff working the evening shift on 11/23/24 was interviewed as part of the investigation. On 12/5/24 at 9:33 AM, Staff 14 (CNA) stated she was Resident 1's assigned CNA for the evening shift on 11/23/24. She returned from her break at approximately 6:30 PM and went to Resident 1's room to check on her/him. Staff 14 stated she was unable to locate the resident and notified the charge nurse. Staff 14 stated she and two other CNAs searched the neighborhood for the resident, who was found by Staff 16 (CNA) a short time later. Staff 14 stated no management came to the facility after the elopement and she was not interviewed by anyone. On 12/5/24 at 9:40 AM, Staff 15 (CNA) stated she was not assigned to Resident 1's hall on 11/23/24, but heard about Resident 1's elopement and decided to search for her/him, along with Staff 14 and Staff 16. Staff 15 stated she observed Resident 1 headed west on a busy street and the resident had walked a long way and was waiting for the bus. Staff 15 stated no management came to the facility after the elopement and she was not interviewed by anyone. On 12/5/24 at 2:15 PM, Staff 16 stated he was working on the other hall and was informed by the charge nurse Resident 1 was missing. Staff 16 stated he walked into a couple of businesses and did not find the resident. He continued to walk west and saw Resident 1 standing at a bus stop. He stated he ran across the street to stop Resident 1 from boarding the bus and if it would have been two minutes later, [the resident] would have been gone. Staff 16 stated he walked with Resident 1 back to the facility. Staff 16 stated no management came to the facility after the elopement and he was not interviewed by anyone. On 12/5/24 at 3:15 PM, Staff 1 (Administrator) reviewed the Investigation and Conclusion Report with this surveyor and confirmed no staff was identified by name, there was no dates or times of interviews, and no CNA staff who participated in Resident 1's search or worked at the time of Resident 1's elopement was interviewed.

Based on observation and interview it was determined the facility failed to provide a comfortable, clean and homelike environment for 1 of 1 dining/activity room and 1 of 1 resident lounge reviewed for environment. This placed residents at risk for an unsatisfying meal and activity experience and living in an institutionalized environment. Findings include: On 3/18/24 at 11:20 AM a resident was observed to sit with a staff member in the resident lounge. They were seated at the table and were surrounded by the following items: -Three mechanical lifts. -Rolling maintenance cart with a hammer and drill on top. -Crash cart (emergency medical equipment). -Lamp. -Large box with containers of disinfectant wipes. -Large weight scale. -Utility ladder. -Empty opened cardboard TV box. -PPE (personal protective equipment) three drawer containers. On 3/18/24 at 11:52 AM the dining/activity room was observed to contain a mechanical lift, a large motorized wheelchair with a tear in the head piece and a worn resident mattress up against the wall. On 3/18/24 at 3:28 PM Staff 1 (Administrator) observed the dining/activity room and resident lounge with the surveyor. Staff 1 acknowledged he expected the residents' dining, activity program and lounge experience to be homelike and the items stored in the dining/activity room and resident lounge were not homelike.

Based on interview and record review, it was determined the facility failed to follow the facility bowel protocol and administer physician ordered medication for 1 of 3 sampled residents (#2) reviewed for bowel monitoring and constipation. This resulted in Resident 2 being severely constipated and receiving a fecal disimpaction while at the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Fecal Impaction is an extreme form of constipation in which the contents of the colon become hard and dry, creating a blockage and making it impossible to have a bowel movement. As a result, the contents of the intestines become backed up, leading to potentially serious complications if left untreated. Signs and symptoms can include chronic constipation, dehydration, fever, confusion, headache, abdominal discomfort, abdominal bloating, abdominal pain and cramping, weak appetite and hardened areas or masses in abdomen. The facility's Bowel Protocol indicated the following: Start Bowel Protocol after nine shifts without BM (bowel movement). If medications do not assist the patient with their constipation after all steps completed, contact the medical doctor for orders. Step 1 - If no BM (bowel movement) after nine shifts and bowel exam with evidence of constipation, give MOM (Milk of Magnesia) 30 ml at bedtime with large glass of water. Step 2 - If no results with with MOM by 5:00 AM, give one [MEDICATION(S)] suppository rectally. Step 3 - If no results from [MEDICATION(S)] suppository after one hour, give one application fleet enema rectally. Resident 2 was admitted to the facility in 12/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/24/19 Clinical Admission Assessment indicated Resident 2's cognitive skills were severely impaired. The resident was incontinent of bowel and had a regular bowel elimination pattern. The last documented bowel movement was on 12/24/19. Resident 2's 12/24/19 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . House standing orders which included the Bowel Protocol were ordered for the resident. A review of Resident 2's facility bowel records for 12/2019 indicated the resident did not have a bowel movement from 12/25/19 to 12/30/19 (six days) over 17 shifts . Resident 2's 12/2019 MARs indicated no PRN bowel medications were offered or provided from 12/24/19 through 12/30/19. There was no documentation the facility followed the bowel protocol after Resident 2 had gone more than nine shifts without a bowel movement. On 12/30/19, Resident 2 was sent to the emergency department for an elevated temperature. The resident was found to have a CAUTI (catheter-associated urinary tract infection) and was admitted to the hospital for [CONDITION(S)] (infection in the blood stream). The resident returned to the facility on [DATE]. The 1/7/20 Hospital Discharge Summary indicated Resident 2 had severe constipation with fecal impaction that was seen on a CT (computerized tomography) scan. A fecal disimpaction (manual fecal removal) was done on 1/1/20. The resident was identified as improving and having daily bowel movements after the disimpaction. The resident was ordered scheduled [MEDICATION(S)] (a laxative) and [MEDICATION(S)] (a stool softener). Orders were to continue aggressive bowel regimen as needed. On 4/16/21 at 12:28 PM and 4/19/21 at 12:56 PM, Staff 1 (Administrator) acknowledged Resident 2 did not receive bowel care interventions as ordered. Staff 1 verified the resident while being treated at the hospital for a UTI back in 1/2020 was identified as being severely constipated with fecal impaction which resulted in a fecal disimpaction.

Based on observation, interview and record review it was determined the facility failed to ensure resident Hoyer lifts were in good working order for 11 of 11 sampled residents (#s 1, 12, 14, 15, 18, 21, 23, 29, 30, 31 and 335) who required Hoyer transfers. This failure, determined to be an immediate jeopardy situation, resulted in Staff 6 (CNA) transferring Resident 29 with a Hoyer lift and the resident fell from the Hoyer and landed on the floor hitting her/his head and sustained a hematoma to the back of her/his head. This placed residents at risk for falls. Findings include: Resident 29 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The 1/15/18 Annual MDS ADL CAA indicated Resident 29 was to receive two person assistance using the mechanical lift. The 1/15/18 Annual MDS Section C indicated Resident 29 had a BIMS (Brief Interview for Mental Status) score of 3 (which indicated severe impairment). The most recent Care Plan dated 4/14/15 indicated Resident 29 required mechanical lift transfers with two person assist. A 1/20/18 Progress Note by Staff 6 indicated Resident 29 slid out of the Hoyer sling and landed on the floor, hitting her/his head. A 1/20/18 Progress Note by Staff 23 (RN) indicated Staff 6 reported Resident 29 was on the floor and found the resident on her/his back on the floor. The resident sustained [REDACTED]. On 1/31/18 at 3:20 PM Staff 6 indicated she transferred Resident 29 on 1/19/18 using the Hoyer lift by herself. She stated the straps of the Hoyer sling moved when the Hoyer was raised and if the black cap was in place at the time of the transfer she believed it would have prevented the fall. When asked to explain further Staff 6 stated the straps from the Hoyer sling slide into place below the black cap and secure the straps in place like a lock. Two Hoyer lifts were observed with Staff 6 both had a black round cap on one side of the Hoyer bar and was missing one black cap on the opposite side. Staff 6 was unsure of how long each of the Hoyer lift caps were broken and had not reported it to staff. On 1/31/18 at 3:38 PM Staff 7 (CNA) stated the black cap on the Hoyer lift protects the sling from falling off. On 1/31/18 at 4:02 PM Staff 5 (DNS) observed both Hoyer lifts and stated that once the sling straps are under the black cap it prevents them from slipping out. She acknowledged both Hoyer lifts currently being used for resident transfers were missing one black cap. She stated Maintenance checks the Hoyer lifts monthly or as needed. She stated staff should notify the nurse and add it to the Maintenance Log if equipment was broken, that the current Maintenance Director had been employed for only four days and was unaware if the previous Maintenance Director had checked the Hoyer lifts. On 1/31/18 at 4:08 PM Staff 8 (Maintenance Director) stated he was unaware of the missing caps on the Hoyer lifts and this was only his fourth day of working at this facility. On 1/31/18 at 4:10 PM Staff 9 (CNA) stated the black cap on the Hoyer lift was used to keep the straps from slipping off the Hoyer. She stated she had noticed the missing black cap and had notified the Maintenance man about two weeks ago. A review of the Maintenance Log did not include information about the Hoyer lifts. On 1/31/18 at 4:38 PM, following consultation with the State survey supervisors, the failure of the facility Hoyer lifts being in good repair constituted a situation of immediate jeopardy to residents. The team requested a plan to be developed and implemented by the facility immediately to protect the residents from harm. On 1/31/18 at 5:00 PM, the abatement plan was provided by the facility that ensured residents safety regarding Hoyer lifts. The abatement plan indicated: -New Hoyer coming from healthcare supply company -Maintenance to check all mechanical lifts and repair -Broken equipment removed from the floor -Educate all staff regarding utilizing the Maintenance Book and report malfunctioning and or broken equipment starting now and continuing on each shift. -Maintenance Director to audit mechanical lift 3-5 days per week -Maintenance Log brought to every stand-up meeting and reviewed with Administrator Monday-Friday -If any equipment is malfunctioning and/or broken on nights or weekends, the Administrator is to be notified immediately -Will review in monthly Quality Assurance and Performance Improvement (QAPI) meetings as well as Labor Relations meetings The facility reported they would use a different Hoyer lift (that was not being used and observed to be in good working order) until the replacement lift arrived. The survey team verified the broken Hoyer lifts were removed from the floor, they were relocated in the Therapy Room and signs were placed on both lifts to not use until repaired.